Difficulty: Medium
Average Score: 69%
Simulated
A nurse is caring for a client who has constipation and is bearing down to have a bowel movement. The nurse should monitor the client for which of the following? A. Decreased heart rate B. Increased respirations C. Increased temperature D. Decreased exhaled carbon dioxide Which of the following should the nurse monitor the client for?
Correct answer
A
Rationale
Rationale: The correct answer is A. Decreased heart rate. When a client is bearing down to have a bowel movement, it can stimulate the vagus nerve, leading to a vasovagal response. This response can cause a decrease in heart rate due to increased vagal tone. Monitoring for a decreased heart rate is important as it can indicate a potential vasovagal episode.
Summary of other choices:
B. Increased respirations: Bearing down for a bowel movement typically does not directly affect respirations.
C. Increased temperature: There is no direct correlation between bearing down for a bowel movement and increased body temperature.
D. Decreased exhaled carbon dioxide: This is not typically associated with bearing down for a bowel movement.
Summary of other choices:
B. Increased respirations: Bearing down for a bowel movement typically does not directly affect respirations.
C. Increased temperature: There is no direct correlation between bearing down for a bowel movement and increased body temperature.
D. Decreased exhaled carbon dioxide: This is not typically associated with bearing down for a bowel movement.